Back to the Future: Back to the Future: A Call to Action for FP A Call to Action for FP

and LAPMsand LAPMs

Scott Radloff

Director

Office of Population and Reproductive Health

USAID

ACQUIRE End-of-Project Meeting

September 17, 2008

Family Planning: responds to a panoply of problems…

Enables couples to decide number/spacing of births Reduces child mortality Reduces maternal mortality/morbidity Reduces abortion Improves women’s opportunities Key intervention in HIV settings Essential component of health programs Mitigates adverse effects of population dynamics

on:– natural resources– economic growth– state stability

Unmet need of 201 million in developing countries translates to:

23 million unplanned births 22 million abortions 2 million miscarriages 1.4 million infant deaths 142,000 pregnancy-related deaths [1/2 in

Africa]

– 53,000 from unsafe abortion

– 89,000 from other causesSource: Guttmacher Policy Review, Summer 2008, Vol 11, Number 3

Pop Quiz Question

As CPR rises, demand for limiting rises

As CPR rises, demand for limiting occurs at earlier ages

Age at which demand for limiting cross demand for spacing by modern CPR, most recent DHS, 44 countries

R2 = 0.822

20

25

30

35

40

45

0 - 10 10 - 20 20 - 30 30 - 40 40 - 50 50 - 60 60 - 70

Modern CPR (married)

Ag

e

Age at which demand for limiting equals demand for spacing by modern CPR, all available DHS since 2000 (n=44)

AnswerPop Quiz

Substantial demand for limiting and spacing in African countries

0

10

20

30

40

50

60

70

Space

Limit

Still, Africa is characterized by high unmet need and low use of LAPMs…

0

10

20

30

40

50

60

70

80

Chad 2004

Niger

 200

6

Guinea

 200

5

Mal

i 200

1

Benin 2

001

Niger

ia 2

003

Burkin

a Fas

o 20

03

Seneg

al 2

005

Rwan

da 20

05

Camer

oon 2

004

Ethio

pia 

2005

Ghana 20

03

Uganda 2

006

Mad

agas

car 2

004

Tanza

nia 2

004

Moza

mbiq

ue 200

3

Zambia

 2002

Mal

awi 2

004

Kenya 2

003

Zimbab

we 200

6

Per

cen

t M

WR

A

LAPMs Modern method (non-LAPMs) use Trad CPR Unmet need

2 children, 30 years of contraceptive use -options:

10,950 pills (1 every day)

360 packets of pills (1 every month)

120 injections (1 every 3 months)

6 implants (1 every 5 years)

3 IUDs (1 every 10 years)

1 sterilization (1 in a lifetime)

LAPMs have lower discontinuation ratesand longer duration of effectiveness…

MethodDiscontinuation

Rate by 1 yrDuration of effectiveness

Pill 50% Daily use

Condom 50% Event use

Injectable 40% 1-3 mos

Implanon 48% 3 yrs

Jadelle/Norplant 25% 5-7 yrs

IUD (hormonal, copper) 25% 5-12 yrs

Sterilization (M/F) 10% lifetimeAQUIRE 2007

Injectables35%

Pills17%

Condoms3%

LAM0%

Traditional17%

Implants5%

IUD6%

Sterilization17%

Source: MEASURE/DHS, Kenya 2003 DHS Survey.Ross, Stover, and Adelaja, 2005.

MWRA (15-49 yr) 5.1 million (2005)

%

LAPM use to limit: 27%LAPM use to limit: 27%

Long-Acting and Permanent Methods

Long-Acting and Permanent Methods

LAPMs are underutilized among limiters in Kenya

Pills18%

Condoms10%

Traditional25%

Injectables39%

IUD4%

Implants4%

Source: MEASURE/DHS, Kenya DHS Survey, 2004.

%

Long-Acting and Permanent Methods

Long-Acting and Permanent Methods

LA use to space: 8%LA use to space: 8%

Long-Acting methods have potential for use among spacers in Kenya

And, LAPMs are suitable for various reproductive intentions…

DD

Long Acting: Implants and IUDs

Delaying first births-Youth-Nulliparous

SS H+H+ LLPermanent: Vasectomy,

Female Sterilization

Spacing pregnancies-Postpartum-Postabortion

HIV+ women can use

any LAPM

Limiting births after desired fertility goals are reached

- High Parity- Low Parity- Any age

TimeSocio-cultural

norms

Cost

Process

Physical

Inappropriate eligibility criteria

Poor CPIProvider

bias

KnowledgeLocation

↑↑ Access

↑↑ Choice

↑↑ Quality

Barriers to LAPM services

Barriers to LAPM services

Outcomes when barriers are overcome:

Outcomes when barriers are overcome:

But, there are still barriers to LAPMs…

BREAK DOWN THAT WALL ! ! !

What can be done to increase the use of LAPMs?

“Unpack” LAPMs

LAPMs ‘Packed’ = specific clinical

requirements for service provision

LAPMs ‘Unpacked’ = suitable for multiple

reproductive intentions – Spacing – Long-acting methods

– Delaying – Long-acting methods

– Limiting – Long-acting methods, permanent methods

“Long-Acting” effectiveness is not the same

as “Long-Term” use (it’s not all or none)

Integrate LAPMs into all other PRH technical priorities…

• Contraceptive security including clinical equipment and supplies

• Community-based FP Frees up clinical capacity for LAPMs, increases referrals

• Healthy timing and spacing of pregnancies IUDs and implants help achieve longer spacing intervals

• FP/MCH integration Postpartum and PAC, immediate use of IUD, M/F

sterilization

• FP/HIV integration All LAPMs are safe methods and good options for HIV/AIDS

Future opportunities for LAPMs…

– The Sino-implant revolution– Meeting the latent, and growing demand for

limiting, at younger ages– Increasing L-A use for spacing, delaying– Reaching postpartum and post-abortion

clients– Engaging private sector services– Expanding approaches to reach rural areas– Expanding urban and peri-urban services– Offering comprehensive men’s health care

BACK (AND FORWARD) TO THE FUTURE

Sometimes, going forwardrequires going back to

“Big, Boring Programs”or

“Proven, Time-Tested ApproachesAdapted to New Settings”

In closing……